W149
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client.
Guidance §483.420(d)(1)
The facility, through implementation of its policies, must set up a structure that screens and trains employees, protects clients and prevents, identifies, investigates and reports abuse, neglect and mistreatment of clients.
The policies must designate who (either by name or title) has the authority to act in the Administrator’s absence and take any immediate corrective actions necessary to assure a client’s safety such as removing a staff person from direct client contact.
"Mistreatment", for the purposes of this guideline, includes behavior or facility practices that result in any type of client exploitation such as financial, physical, sexual, or criminal.
Mistreatment also refers to the use of behavioral management techniques outside of their use as approved by the specially constituted committee and facility policies and procedures.
"Neglect" means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Staff failure to intervene appropriately to prevent self-injurious behavior may constitute neglect. Staff failure to implement facility safeguards, once client to client aggression is identified, may also constitute neglect.
Refer to W127 for definitions of abuse.
W150
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(1)(i) Staff of the facility must not use physical, verbal, sexual or psychological abuse or punishment.
W151
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(1)(ii) Staff must not punish a client by withholding food or hydration that contributes to a nutritionally adequate diet.
W152
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(1)(iii) The facility must prohibit the employment of individuals with a conviction or prior employment history of child or client abuse, neglect or mistreatment.
Guidance §483.420(d)(1)(iii)
The facility is required to screen potential employees for a prior employment history of child or client abuse, neglect or mistreatment, as well as for any conviction based on those offenses.
The abuse, neglect or mistreatment must have been directed toward a child or a
client/resident/patient of a health care facility in order for the prohibition of employment to apply.
No one with a conviction or substantiated allegation of child or client abuse, neglect or
mistreatment regardless of employment date, is employed by the facility. This requirement also applies to acts of abuse, neglect or mistreatment committed by a current ICF/IID employee outside the jurisdiction of the ICF/IID (e.g., in the community or in another health care facility).
The facility must follow state guidelines or requirements for background checks to assure that they make every effort to check new employee’s background.
Where the facility has terminated an employee based upon confirmation that abuse, neglect or mistreatment occurred during the employee’s performance, and the termination decision was
overturned by either arbitration finding or a court finding, the employee must be returned to a position which does not involve direct contact between that employee and clients of the facility.
A person who abused a resident in a nursing facility, and as a result, is barred from employment in the nursing home setting would also be prohibited from employment in the ICF/IID. While facilities are not required to periodically screen existing employees, if the facility becomes aware that such action has been taken against an employee, the facility is required to prohibit continued employment. This is also true of any conviction in a court of law for child, elder, or client (resident, patient) abuse, neglect or mistreatment. Therefore, conviction for abusing one's own child is also a reason employment would be prohibited.
W153
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(2) The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Guidance §483.420(d)(2)
Injuries of unknown source that give rise to a suspicion that they may be the result of abuse or neglect, should be reported immediately.
An injury should be reported as an “injury of unknown source” when:
• The source of the injury was not witnessed by any person and the source of the injury could not be explained by the client; and
• The injury raises suspicions of possible abuse or neglect because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally
vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.
It is important to note that members of the ICF/IID population are a mobile population and lead active lives. Therefore, they experience normal day-to-day bumps and minor abrasions as they go about their lives. These minor occurrences which are not of serious consequence to the individual and do not present as a suspicious or repetitive injury (as discussed above) should be recorded by the facility staff once they are aware of them and follow-up should be conducted as indicated. For injuries that do not rise to the level of reportable “injuries of unknown source”, the facility should follow its policies and procedures for incident recording, investigation, and tracking.
The facility must immediately report any suspicious injuries of unknown source and all
allegations of mistreatment, neglect or abuse to a client residing in the facility regardless of who is the alleged perpetrator (e.g., facility staff, parents, legal guardians, volunteer staff from outside agencies serving the client, neighbors, or other clients, etc.).
If state law requires reporting to an agency or entity other than the administrator, the Centers for Medicare & Medicaid Services (CMS) expects the administrator to be notified as well, in order to ensure facility response to promptly safeguard the client(s).
For the purposes of this regulation “immediately” means there should be no delay between staff awareness of the occurrence and reporting to the administrator or other officials in accordance with State law unless the situation is unstable in which case reporting should occur as soon as the safety of all clients is assured.
W154
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(3) The facility must have evidence that all alleged violations are thoroughly investigated and
Guidance §483.420(d)(3)
In the absence of any pre-survey information that would indicate the need for a more thorough review of reports of investigation, review 5 percent of the total client investigations for the last three (3) months (but no less than 10).
A thorough investigation includes at a minimum:
• The collection of all interviews, statements, physical evidence and any pertinent maps, pictures or diagrams;
• Review of all information;
• Resolution of any discrepancies;
• Summary of conclusions; and
• Recommendations for action both to safeguard all the clients during the investigation and after the completion of the report.
If patterns of possible abuse, mistreatment or neglect are identified, or the incident report logs for the past three (3) months indicate an extremely high incident rate, then a full review of the incidents for the past three (3) months should be completed.
W155
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(3) must prevent further potential abuse while the investigation is in progress.
Guidance §483.420(d)(3)
The facility must take all measures necessary to protect the client, including removal of the staff from working with the client if indicated. See W154.
W156
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(4) The results of all investigations must be reported to the administrator or designated representative or to other officials in accordance with State law within five working days of the incident and,
Guidance §483.420(d)(4)
Some states require that allegations of abuse must be reported to the police. A police investigation may take longer than five (5) working days. Their investigation does not change the requirement that the facility must complete an internal investigation report of findings within the five day timeframe. When outside authorities are involved, the facility will still be required to complete their investigation within five days to the extent authorized by such entities. "Working days" means Monday through Friday, excluding state and Federal holidays.
W157
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)
§483.420(d)(4) if the alleged violation is verified, appropriate corrective action must be taken.
Guidance §483.420(d)(4)
The facility is required to ensure that clients residing in the facility are not subjected to physical, verbal, sexual or psychological abuse or punishment.
Appropriate corrective action is required for findings of abuse, neglect or mistreatment by other clients residing in the facility, staff of outside agencies, parents or any other person, and for injuries to clients resulting from controllable environmental factors.
If the facility receives allegations of abuse, neglect, or mistreatment of a client during out of facility visits with their family, they must report these allegations to the appropriate state authority for investigation. The facility does not have to conduct an internal investigation regarding the alleged violation.
Appropriate corrective action is defined as that action which is reasonably likely to prevent the abuse, neglect, mistreatment or injury from recurring.
This regulation does not require staff termination as the only appropriate corrective action.
The corrective action imposed by the facility is commensurate with the violation.
When a facility is forced to re-hire a staff person, determined by the facility investigation to have been responsible for abuse, neglect, or mistreatment, the facility continues to be responsible for ensuring the health and safety of the clients, and ensures that those staff members do not work directly with clients.
W158
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15)